The nurse is caring for a one-month-old baby girl who has myelomeningocele. Assessment findings reveal that the infant has a temperature of 37.9°C. The initial action of the nurse is to:

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The initial action of the nurse when the infant has a fever is to immediately report this to the physician. Myelomeningocele is characterized by non-fusion of the spine, resulting in protrusion of the spinal contents. The spine is covered by a thin membranous sac that is highly susceptible to infection and injury. Assessing the sac for feces or urine contamination and recording the vital signs are secondary actions of the nurse. Sponge bath to decrease the infant's temperature may compound the infant's condition because of unnecessary exposure to cold.

The Nurse Is Caring for a One-Month-Old Baby Girl Who